The Science of Gender: what influences gender development and gender dysphoria

With thanks to Bob Withers for the original work dated 23 October 2018. I have taken Bob’s words unabridged and added my comments in italics. This was a write-up of The 2018 European Society for Paediatric Endocrinology (ESPE) Science Symposium on 18-19 October 2018 at The Tavistock and Portman NHS Foundation Trust entitled ‘The Science of Gender: Evidence for what influences gender development and gender dysphoria and what are the respective influences of nature and nurture’. Where I think Bob’s words require emphasis, I do so in bold. Bob’s references are at the end of his text and my comments follow these. Anyway, on with Bob’s synopsis…

This conference was funded by Pfizer pharmaceuticals, though apparently the Tavistock Gender Identity Service was given total freedom regarding the subject matter of the symposium.

Professor Gary Butler of UCLH and the Tavistock GIDS introduced proceedings. He remarked that no chromosomal, hormonal, or other physical anomalies had been detected in the clinical population using the GIDS, despite initially screening for these.

Dr Polly Carmichael, head of the GIDS and a clinical psychologist, went on to give the first talk. It concerned the differences and similarities between gender dysphoria and sex development disorders. Surprisingly, given her profession and the stated purpose of the conference, Polly did not mention psychological factors influencing gender development. Instead she emphasised genetic, biological and social elements. When questioned about this omission she described it as a ‘Freudian slip’. The omission is surprising given the Tavistock’s position as a leading psychoanalytic clinic and the preoccupation with identity development in psychoanalysis. Freud’s (1917) Mourning and melancholia, Winnicott’s (1967) ‘mirroring’ and the Boston Change Process Study Group’s recent (2010) work on the role of implicit relational knowing in the construction of the inner world are all deeply concerned with the development of identity.

Unfortunately, this reluctance to address psychological factors proved to be a feature of the conference. There was not a single talk on the role of psychological factors in the aetiology of gender dysphoria or gender identity. But Professor Riittakerttu Kaltiala-Heino, an adolescent psychiatrist from Tampere Finland, did acknowledged the importance of a psychodynamic perspective. She spoke about her clinical experiences- including her work with ‘adolescent onset gender dysphoria’, sometimes known as ‘Rapid Onset Gender Dysphoria (ROGD)’. She made several important points, observing for instance that in Finland, as elsewhere, psychological co-morbidities remain largely untreated because psychotherapists wrongly believe that only gender identity specialists should treat GD patients. In her experience, such co-morbidities are likely to persist if they are not addressed psychologically before medical treatment. Interestingly she also mentioned that several of her patients seemed to share an identity. Many of the young FtMs in her care claimed to have spent large parts of their childhood alone in the woods fantasising about being a male wolf for instance. She acknowledged privately that this was probably due to social contagion via the internet as people were encouraged to provide the sort of history that would facilitate their medical transition.

(See comment 1 below)

In contrast Professor Sarah-Jayne Blakemore of UCL spoke about the science of brain development in adolescence. She outlined the move through adolescence from puberty to the establishment (if all goes well) of an independent role in society by about the age of 26. Over this period a kind of pruning happens in the social brain network. Grey matter shrinks, and white matter increases in areas of the brain associated with social interaction as connections between and within these areas become myelinated. This process is mediated by the sex hormones of puberty and a cascade of effects occurs down a specific time line. Puberty blockers are likely to interfere with this, but exactly how is currently unknown.

We do know something of the effect of puberty blockers on the brain development of adolescent sheep however. Professor Neil Evans of the Institute of biodiversity in Glasgow reported impairments to several functions, including a sheep’s capacity to find its way through a maze, which persist after stopping puberty blockers. This raises questions about the possible neurological effects of puberty blockers on children’s psychological, social, sexual and cognitive development. Some of Professor Evans’s references are listed below (Robinson et al 2014, Hough et al 2017 a & b).

Puberty blockers have been approved for precocious puberty in humans, but their use in gender dysphoria remains off label. My understanding is that this means that individual doctors (in the USA) and NHS trusts and their doctors (in England) not the drug companies will be liable for any eventual compensation claims. Carmen Mironovici (a paediatric endocrinologist) estimated that the cost of such treatment (in the USA) is currently $15,000 per year.

A couple with a gender dysphoric child and a natal female who had started testosterone treatment and then stopped it after embarking on psychotherapy, kindly shared their experiences with the audience. It became clear that the current set up at the GIDS typically only offers six psychological assessment sessions and a similar number of family therapy sessions with little or no meaningful ongoing individual psychotherapy. This is inadequate for a client trying to deal with serious comorbidities such as childhood sexual abuse, autism, attachment issues, body hatred and/or struggles with their sexuality- including internalised homophobia. And it seems likely that in at least some cases such psychological issues play a significant role in the aetiology of trans identification.

On the first evening, a series of clinical case scenarios and the ethical issues raised by them were discussed in small groups and précised for a plenary session. One case was that of a young person who had been diagnosed gender dysphoric and prescribed puberty blockers by the GIDS. They had been fortunate enough to receive meaningful psychotherapy and as a result came to realise that their trans identification had been a reaction to psychological trauma. Some of the ethical issues raised were these:

How often are trans identification and puberty blockers currently being used by clinicians, clients and their families to evade the investigation of painful psychological issues?

How ethical is the use of puberty blockers given our ignorance of their long-term effects?

Do they buy time for a GD young person to explore their options before deciding whether to embark on full physical transition, or do they increase the probability of medical transition?

Another question that could have been raised is whether the lack of effective psychotherapy at the GIDS is really justified,given the high cost and potential side effects of puberty blockers.

There is not enough space in this review to outline all the talks, let alone critique them all effectively. Dr Vibe Frokjaer of Denmark spoke informatively on the role of hormones in the aetiology of mental health problems, including depression,in women. Dr Annelou de Vries quoted a 2011 Dutch study by Steensma et al which indicated that childhood gender dysphoria only persists past puberty in 15% of cases, while 75% persist if still dysphoric after the onset of puberty. Some talks dealt with the genetics of gender (or more properly sex) development (Skordis). Some (Fisher, Seal) summarised the research on the effects of medical intervention on bone, cardio vascular and cancer morbidity. Effects were complex and varied depending on the length of time of the study, the precise nature of the treatment and the gender of the patient. Trans men’s health generally fared better than trans women’s. A long-term study by Asscherman et al (2011) showed a 51% increase in mortality among medically treated trans women.This was mainly due to suicide and HIV/AIDS.

(See comment 2 below)

Dr Leighton Seal of the Charing Cross (adult) Gender Dysphoria Clinic reported an 80% reduction in psychological symptoms 78% improvement in well-being and 72% improvement in sexual function among his subjects post medical transition. It is unclear how this squares with the long term increased suicide risk however. Dr Seal also claimed that a (Zhou et al 1995) post-mortem study of seven trans women all of whom had received female sex hormones, six with full orchiectomies, provided good evidence that gender dysphoria was caused by abnormalities in foetal brain development. It is hard to understand how he reached such a conclusion.

(See comment 3 below)

For me this symposium failed in its central aim of helping distinguish the respective roles of nature and nurture in gender development and gender dysphoria; largely because it failed to give due weight to psychological factors. Perhaps this is to be expected from a conference sponsored by a large multi-national pharmaceutical company. Nevertheless, it was a very welcome conference, which facilitated informative, at times robust, but generally mutually respectful discussion among a group of professionals from all over the world. I look forward to a similar but more truly interdisciplinary conference in the not too distant future.

(1) It is incredibly important in setting out any treatment protocol for cross-sex identification or gender dysphoria that we recognise three important facts about the condition and how this arises. What we understand by ‘gender dysphoria’ is not a single discrete condition with a single cause: there is no physiological condition that is to be ‘born in the wrong body’. There are differing types of transgender in males and females, in each case connected to sexual orientation. In recent years, the historically low number of females seeking cross-sex treatments has risen dramatically and the phenomena Professor Kaltiala-Heino is referring to, ‘rapid onset gender dysphoria’ (‘ROGD’), appears to be at the heart of this rise. There have been concerted efforts to suppress scientific discussion of ROGD which is clearly not in the interests of the children this is affecting; whether ROGD is a thing or not is a scientific question, not an ideology, and we are neglecting the best interests of trans-identifying children by shutting down scientific enquiry and debate.

(3) Dr Leighton Seal is supposed to be one of this country’s most esteemed endocrinologists. I find it more than weird that he’s producing arguments as archaic as ‘brain sex’-style causation especially as the Zhou study, with n=7 and no control for hormone use, is so incredibly weak. Time and time again it is produces as evidence for how being trans is a pre-natal condition, when the study does no such thing, and Seal’s claim is incredibly sloppy as, in the words of Anne Lawrence’s own critique of Zhou’s paper:

The simplest and most plausible explanation of the Zhou/Kruijver findings is that they are attributable, completely or predominantly, to the effects of cross-sex hormone therapy administered during adulthood. There is no longer any reason to postulate anything more complicated.

…discrimination against gay people still exists. And as I’ve watched as glowing stories about transgender children have flooded every progressive news outlet over the last few years, every one of them appalls and saddens me. Because the underlying story that the public isn’t privy to is that many of these children would have grown up to be gay, but are instead undergoing a new form of conversion therapy.

It is unconscionable that the interests of children are being neglected in favour of supporting a dogma which supports adults who have (usually) lived full lives before their transition, and that these adults are directly denying the rights of these children to enjoy the same opportunities these adults have themselves enjoyed.